Tennessee



Tennessee Department of Children’s ServicesInitial Intake, Placement and Well-Being Information and HistoryChild Name: FORMTEXT ????? Child DOB: FORMTEXT ????? Person ID: FORMTEXT ????? Initiated By: FORMTEXT ?????Title: FORMTEXT ?????Date: FORMTEXT ?????Revised By: FORMTEXT ?????Title: FORMTEXT ?????Date: FORMTEXT ?????Person Providing Information to DCS: FORMTEXT ?????Relationship to Child/Youth: FORMTEXT ?????Current insurance coverage FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown If yes, provide details: FORMTEXT ?????Child/Youth InformationName of Child/Youth: REF ChildsFullName \h E-mail Address: FORMTEXT ?????SSN: FORMTEXT ?????DOB: REF ChildsDOB \h Sex: FORMTEXT ?????Race: FORMDROPDOWN Hispanic: FORMCHECKBOX Yes FORMCHECKBOX NoU.S. Citizen: FORMCHECKBOX Yes FORMCHECKBOX No Provide Birth Certificate VerificationIs Child/Youth of Native American Descent? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unable to DetermineIf “Yes” Tribal Affiliation FORMTEXT ?????Child/Youth’s Marital Status (check one) FORMCHECKBOX Never Married FORMCHECKBOX Divorced FORMCHECKBOX Widowed FORMCHECKBOX Married FORMCHECKBOX SeparatedHas Youth been placed in out of home care prior to this custody episode? If yes please list dates and placements: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoCurrent Description of the Child/YouthPhysical Description Date FORMTEXT ?????Primary Language Spoken FORMTEXT ?????Height FORMTEXT ?????Weight FORMTEXT ?????Hair Color FORMTEXT ?????Eye Color FORMTEXT ?????Religion: FORMTEXT ?????Identifying Marks or Tattoos: FORMTEXT ?????Special Needs/Disabilities: FORMTEXT ?????Special Medical Equipment: FORMTEXT ?????Scheduled Appointments: (date, provider, location, type of appt) FORMTEXT ?????Allergies/Adverse Reactions: FORMCHECKBOX Yes FORMCHECKBOX No Medication: FORMTEXT ?????Describe reaction: FORMTEXT ?????Food: FORMTEXT ?????Describe reaction: FORMTEXT ?????Insect Sting: FORMTEXT ?????Describe reaction: FORMTEXT ?????Other: FORMTEXT ?????Describe reaction: FORMTEXT ?????Medical modified/Religious diet? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe FORMTEXT ?????Medications: Prescribed and Over the CounterCurrent medications (name, route, frequency, dosage & days of meds left) FORMTEXT ????? FORMTEXT ?????Child Name: REF ChildsFullName \h Child DOB: REF ChildsDOB \h FORMTEXT ????? Person ID: REF ChildsPersonID \h Are meds given in school? FORMCHECKBOX Yes FORMCHECKBOX No Which meds? FORMTEXT ?????Consent signed for psychotropic meds: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A Next med appointment: FORMTEXT ?????Has Foster Parent received medication: FORMCHECKBOX Yes FORMCHECKBOX No Explain: FORMTEXT ?????Health History of Child Explain any items checked Now/Past in "COMMENTS" sectionNoNowPast?NoNowPast? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Birth defects FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Gastrointestinal problems FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Vision problems FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Kidney/urinary problems FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Hearing problems FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Hepatitis/liver problems FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Skin problems FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cancer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Head injuries FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Tuberculosis (TB) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Headaches FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Autism/Asperger's (circle one) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sickle cell disease FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Developmental delays FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Anemia/blood disorder FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Learning disability FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Epilepsy/seizures FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sleep problems FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Bedwetting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Incontinence: FORMCHECKBOX Urine FORMCHECKBOX Stool FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Diabetes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other medical (describe below) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Asthma/Respiratory Disease FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Accidents (describe below) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Heart murmur FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Hospitalizations (describe below) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Heart problems FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Surgeries (describe below) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX High blood pressure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Problems with anesthesia FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Physical disabilities FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other developmental disabilitiesChild/Youth is currently hospitalized: FORMCHECKBOX Yes FORMCHECKBOX No If yes, where and why: FORMTEXT ????? FORMTEXT ?????Comments/Additional health information/ongoing health related services: FORMTEXT ????? FORMTEXT ?????Childhood Illnesses??????NoYesApprox date?NoYesApprox date? FORMCHECKBOX FORMCHECKBOX ? FORMTEXT ?????Measles FORMCHECKBOX FORMCHECKBOX ? FORMTEXT ?????Chicken pox FORMCHECKBOX FORMCHECKBOX ? FORMTEXT ?????German measles FORMCHECKBOX FORMCHECKBOX ? FORMTEXT ?????Scarlet fever FORMCHECKBOX FORMCHECKBOX ? FORMTEXT ?????Mumps FORMCHECKBOX FORMCHECKBOX ? FORMTEXT ?????Rheumatic feverTrauma Screening???Indicate known history of abuse/adverse experiences. Explain any yes answers in "COMMENTS" sectionNoYes?NoYes? FORMCHECKBOX FORMCHECKBOX Neglect FORMCHECKBOX FORMCHECKBOX Domestic violence FORMCHECKBOX FORMCHECKBOX Physical assault/abuse FORMCHECKBOX FORMCHECKBOX School violence FORMCHECKBOX FORMCHECKBOX Sexual assault/abuse FORMCHECKBOX FORMCHECKBOX Community violence FORMCHECKBOX FORMCHECKBOX Emotional abuse FORMCHECKBOX FORMCHECKBOX Extreme interpersonal violence FORMCHECKBOX FORMCHECKBOX Traumatic loss/separation FORMCHECKBOX FORMCHECKBOX Natural disaster FORMCHECKBOX FORMCHECKBOX Extended illness/medical trauma FORMCHECKBOX FORMCHECKBOX Impaired caregiver (substance abuse/mental illness) FORMCHECKBOX FORMCHECKBOX Serious injury FORMCHECKBOX FORMCHECKBOX Other trauma, describe: FORMTEXT ?????Child Name: REF ChildsFullName \h FORMTEXT ?????Child DOB: REF ChildsDOB \h Person ID: REF ChildsPersonID \h FORMTEXT ?????Has abuse been reported? FORMCHECKBOX Yes FORMCHECKBOX No If no, call CPS 877-237-0026Comments/Additional health information: FORMTEXT ????? FORMTEXT ?????Child Strengths FORMTEXT ?????Behavioral/Mental Health History NoNow Past? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Intense anger, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Oppositional, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Negative Peer Association, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extreme Attention Seeking, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Makes False Statements, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX School Difficulties, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Damage of Property, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Habitual Lying, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Stool Smearing, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Stealing, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Runaway, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Hoarding, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Problems with concentration and attention,if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Excessive Hyperactivity/does not respond to safety instructions, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Requires Constant Supervision, if yes describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Anxiety, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Depression, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Seeing or hearing things that aren't there, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Fire-setting, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Animal cruelty, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Animal fear, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Self-injurious behavior/Other Self Harm, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Aggressive, dangerous or destructive behaviors, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sexual aggression, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Had homicidal thoughts, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Had suicidal thoughts, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Attempted suicide If yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Had other mental health or behavioral problems, if yes, describe FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other mental health diagnosis, if yes, describe FORMTEXT ?????Has the Child/Youth received counseling or therapy? FORMCHECKBOX Yes FORMCHECKBOX No If yes, where? FORMTEXT ?????Has the Child/Youth had a Psychological Evaluation: FORMCHECKBOX Yes FORMCHECKBOX No If yes, diagnosis, when, where? FORMTEXT ????? FORMTEXT ?????Child Name: REF ChildsFullName \h Child DOB: REF ChildsDOB \h Person ID: REF ChildsPersonID \h Has the Child/Youth been hospitalized for mental health problems/acute hospitalization? FORMCHECKBOX Yes FORMCHECKBOX No If yes, diagnosis, when, where? FORMTEXT ????? FORMTEXT ?????Has the Child/Youth/Family received in-home services? FORMCHECKBOX Yes FORMCHECKBOX No If yes, when, where? FORMTEXT ?????Has the Child/Youth previously been placed in a residential treatment facility? FORMCHECKBOX Yes FORMCHECKBOX No If yes, when, where? FORMTEXT ?????Alcohol/Drug Abuse HistoryNoNowPast Frequency(Xs per day/week/month) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Alcohol FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Tobacco smoke/chew (circle one or both) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????E-cigarettes/vapor cigarettes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Marijuana FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Narcotics FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Stimulants FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Methamphetamine FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Hallucinogens FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Steroids FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Huffing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Ecstasy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Street drugs, unknown FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Prescription drugs prescribed for another, specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Over-the-counter medication, specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Other, specify: FORMTEXT ?????Additional Comments: FORMTEXT ?????Has child been identified as high risk? FORMCHECKBOX Yes FORMCHECKBOX NoHas a Safety Plan been completed on child identified as high risk? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A Birth History (for all children)Birth Weight: FORMTEXT ?????Birth Length: FORMTEXT ????? FORMCHECKBOX Full term or FORMCHECKBOX Premature birth (<36 weeks) FORMTEXT ?????weeksDid mother receive prenatal care: FORMCHECKBOX Yes FORMCHECKBOX No Month of pregnancy for 1st prenatal visit: FORMTEXT ?????Pregnancy/Birth complications: FORMTEXT ?????Was there prenatal substance abuse: FORMCHECKBOX Yes FORMCHECKBOX No Substance and frequency: FORMTEXT ?????Birth hospital and location: FORMTEXT ?????Minor FemaleAge of 1st Period: FORMTEXT ?????Date of Last Period: FORMTEXT ?????Pregnancies # FORMTEXT ?????Live births # FORMTEXT ?????Full term FORMTEXT ?????Premature (# weeks) FORMTEXT ?????Miscarriages # FORMTEXT ?????Abortions # FORMTEXT ?????Currently pregnant: FORMCHECKBOX Yes FORMCHECKBOX No If yes, due date: FORMTEXT ?????Child Name: REF ChildsFullName \h Child DOB: REF ChildsDOB \h Person ID: REF ChildsPersonID \h Does the youth have children? FORMCHECKBOX Yes FORMCHECKBOX No If yes, answer below questions:Youth’s Children’s NamesDOBIn DCS Custody?Male/Female?RaceName of Person Child Lives with and RelationshipName of Child’s Other ParentContact Information of Other Parent FORMTEXT ????? FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Does minor parent have visitation with their child(ren)? FORMCHECKBOX Yes FORMCHECKBOX No If yes, list any visitation restrictions: FORMTEXT ?????Gender and Sexual IdentityDoes the Child/Youth identify him/herself as gay, lesbian, transgender, or non-binary? FORMCHECKBOX Yes FORMCHECKBOX No If yes, describe answer FORMTEXT ?????Sexual ActivityIs child sexually active? FORMCHECKBOX Yes FORMCHECKBOX NoUse birth control? FORMCHECKBOX Yes FORMCHECKBOX NoMethod: FORMTEXT ?????Dating ViolenceHas Child/Youth experienced controlling, abusive or aggressive behavior in a dating relationship? FORMCHECKBOX Yes FORMCHECKBOX No If yes, explain: FORMTEXT ?????MedicalDoes the Child/Youth have a regular medical provider (pediatrician, family doctor, etc.)? FORMCHECKBOX Yes FORMCHECKBOX No If yes, name of medical provider: FORMTEXT ?????Date of last visit: FORMTEXT ?????ImmunizationsAre immunizations up-to-date? FORMCHECKBOX Yes FORMCHECKBOX No Is the immunization record available? FORMCHECKBOX Yes FORMCHECKBOX No Religious/medical exemption? FORMCHECKBOX Yes FORMCHECKBOX No (parent/guardian must provide a notarized statement)DentalDoes the Child/Youth have a regular dental provider? FORMCHECKBOX Yes FORMCHECKBOX No Does the Child/Youth wear braces? FORMCHECKBOX Yes FORMCHECKBOX No If yes, name of dental provider: FORMTEXT ?????Date of last exam: FORMTEXT ?????If braces, name of orthodontist: FORMTEXT ?????Date of last exam: FORMTEXT ?????VisionDoes the Child/Youth wear glasses? FORMCHECKBOX Yes FORMCHECKBOX No Does the Child/Youth wear contacts? FORMCHECKBOX Yes FORMCHECKBOX No If yes, name of vision provider: FORMTEXT ?????Date of last visit: FORMTEXT ?????This concludes the Well-Being Section. This page intentionally left blank.Child Name: REF ChildsFullName \h Child DOB: REF ChildsDOB \h Person ID: REF ChildsPersonID \h This information does not go to Health Care Provider.Education and Independent LivingStudent graduated high school? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX GED FORMCHECKBOX HISET FORMCHECKBOX Student Home SchooledWhat school does the student attend? (name, city, county) FORMTEXT ?????Student’s age FORMTEXT ?????Current grade FORMTEXT ?????Student receives special education services? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, name the disability FORMTEXT ?????NoYes? FORMCHECKBOX FORMCHECKBOX Is the student taking GED classes FORMCHECKBOX FORMCHECKBOX Does the student have a history of skipping school? FORMCHECKBOX FORMCHECKBOX Is the student in an alternative school? FORMCHECKBOX FORMCHECKBOX Is the student serving a zero tolerance expulsion (drugs, weapons and/or assault)? FORMCHECKBOX FORMCHECKBOX Is the student serving a suspension for issues other than zero tolerance? If yes, what is the reason and duration of suspension? FORMTEXT ?????Student strengths (check all that apply)Areas needing improvement (check all that apply) FORMCHECKBOX Mathematics FORMCHECKBOX Mathematics FORMCHECKBOX Reading FORMCHECKBOX Reading FORMCHECKBOX Athletics FORMCHECKBOX Athletics FORMCHECKBOX Attendance in school FORMCHECKBOX Attendance in school FORMCHECKBOX Other, specify FORMTEXT ????? FORMCHECKBOX Other, specify FORMTEXT ?????Other things you would like to share regarding your student’s schooling? FORMTEXT ????? FORMTEXT ?????Presenting and Previous Court Actions on Youth (Unruly/Delinquent Youth only)Current Dispositional Information FORMTEXT ?????Disposition Judge FORMTEXT ?????Special Judge FORMTEXT ?????Current Disposition Court FORMTEXT ?????Current Disposition Decision FORMTEXT ?????Disposition Date FORMTEXT ?????Have you been or are you currently on probation? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, where FORMTEXT ?????Defense Attorney FORMTEXT ?????Current Adjudication Type FORMTEXT ?????Current Adjudication Date FORMTEXT ?????Adjudicated Charge – Current and PreviousDate OccurredDisposition DateDisposition FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Pending ChargesCourt Date SetDate (if yes) FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Violation of Probation (VOP) or Violation of Valid Court Order (VVCO) (explain if applicable) FORMTEXT ?????Child Name: REF ChildsFullName \h Child DOB: REF ChildsDOB \h Person ID: REF ChildsPersonID \h Narrative FORMTEXT ?????Legal/Probation Services Previously Offered to Child/YouthDateTypeOutcome FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Safety (Unruly/Delinquent Youth only)A) Maltreatment Allegations or Unruly Behaviors/DelinquencyOther (explain) FORMTEXT ?????Narrative FORMTEXT ?????Strengths (Signs of Safety) FORMTEXT ?????Risks, Needs and Concerns (Signs of Risk include aggressive behavior, arson, cruelty to animals, gang involvement, etc.) FORMTEXT ?????B) Domestic ViolenceNarrative FORMTEXT ?????Strengths (Signs of Safety) FORMTEXT ?????Risks, Needs and Concerns (Signs of Risk include aggressive behavior, arson, cruelty to animals, gang involvement, etc.) FORMTEXT ?????FSW Name FORMTEXT ?????Contact # FORMTEXT ?????Office Address FORMTEXT ?????Supervisor FORMTEXT ?????Contact # FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DCS / Provider StaffDateI acknowledge receipt of the Intake, Placement, and Well-Being Information and History. I further acknowledge my legal duty to maintain confidentiality of this information and history and any additional information I may receive pursuant to Tennessee Code Annotated §37-2-415, The Foster Parent Rights Act. FORMTEXT ????? FORMTEXT ?????Foster ParentDate FORMTEXT ????? FORMTEXT ?????Foster ParentDateThis page intentionally left blank.Child Name: REF ChildsFullName \h Child DOB: REF ChildsDOB \h Person ID: REF ChildsPersonID \h Do not provide this section to the Foster Parent or the Health Care Provider.Has the child/Youth been adopted: FORMCHECKBOX Yes FORMCHECKBOX No: Was the child/Youth in Permanent Guardianship: FORMCHECKBOX Yes FORMCHECKBOX NoReceiving Adoption Assistance or Subsidized Permanent Guardianship: FORMCHECKBOX Yes FORMCHECKBOX No: If yes, Amount: FORMTEXT ????? (If yes, immediately notify the Permanency Specialist, Child Welfare Benefits Counselor Regional and Central Office Fiscal Staff). Adoption/Guardianship Completed by DCS: FORMCHECKBOX Ye FORMCHECKBOX Yes FORMCHECKBOX No (If no List Name of the Agency) FORMTEXT ?????Removal Date: FORMTEXT ????? New Placement: FORMTEXT ?????Date of Placement: FORMTEXT ?????Legal Custody Date: FORMTEXT ?????RemovalCounty: FORMTEXT ?????Adjudication Type:Brief Description: FORMCHECKBOX Dependent and Neglect FORMCHECKBOX Unruly FORMCHECKBOX Delinquent FORMCHECKBOX N/A FORMTEXT ?????Removal Reason: FORMCHECKBOX Alcohol Abuse (Child); FORMCHECKBOX Alcohol Abuse (Parent); FORMCHECKBOX Caretaker Inability to Cope due to Illness or Other: FORMCHECKBOX Child’s Disability; FORMCHECKBOX Drug Abuse (Child); FORMCHECKBOX Drug Abuse (Parent); FORMCHECKBOX Inadequate Housing; FORMCHECKBOX Incarceration of Parents; FORMCHECKBOX NAS Prosecution (only select upon DCS attorney instruction); FORMCHECKBOX Physical Abuse (alleged/reported); FORMCHECKBOX Relinquishment; FORMCHECKBOX Sexual Abuse (alleged/reported); FORMCHECKBOX TruancyRemoval Street Address FORMTEXT ?????City FORMTEXT ?????County FORMTEXT ?????State FORMTEXT ??Zip Code FORMTEXT ?????Kinship Exception RequestWas KER approved? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, by whom? FORMTEXT ?????Was the KER temporary or long term? FORMCHECKBOX temporary FORMCHECKBOX long termMSW Consult was completed with: FORMTEXT ?????Family InformationBoth parents living? FORMCHECKBOX Yes FORMCHECKBOX No If no, date(s) of death: FORMTEXT ????? FORMTEXT ?????Household income to determine IV-E eligibility: (including SS Benefits, SSI for child, AFDC, Foodstamps, Child Support, etc.) If additional supports are received, please indicate in whose name the payment/support is made. FORMTEXT ?????Child/Youth Parent(s)/Caretaker(s)Indicate Parent/Caregiver’s Preferred Method for Receiving DocumentsBirth Mother’s Name FORMTEXT ????? Primary Caregiver FORMCHECKBOX Yes FORMCHECKBOX NoEmail Address FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoMaiden Name FORMTEXT ?????Social Security No. FORMTEXT ?????DOB FORMTEXT ?????Message Contact # FORMTEXT ?????Address FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoCity, State, Zip FORMTEXT ?????Contact # FORMTEXT ?????Employer FORMTEXT ?????Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Contact # FORMTEXT ?????Child Name: REF ChildsFullName \h Child DOB: REF ChildsDOB \h Person ID: REF ChildsPersonID \h \* MERGEFORMAT Birth mother married when child/Youth was born? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unable to DetermineBirth mother ever been married? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unable to DetermineIf so, where and to whom? FORMTEXT ?????Birth mother ever been divorced? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unable to DetermineIf so, where and from whom? FORMTEXT ?????Birth mother’s race: FORMDROPDOWN Is there a father listed on the birth certificate? FORMCHECKBOX Yes FORMCHECKBOX NoHas DNA testing ever been done? FORMCHECKBOX Yes FORMCHECKBOX NoIf so, what were the results and where was it done? FORMTEXT ?????Has there ever been a legal father identified (either mother was married at the time of birth or a father has been legitimated through the court)? FORMCHECKBOX Yes FORMCHECKBOX NoLegal Father’s Name FORMTEXT ????? Primary Caregiver FORMCHECKBOX Yes FORMCHECKBOX NoEmail Address FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoSocial Security No. FORMTEXT ?????DOB FORMTEXT ?????Message Contact # FORMTEXT ?????Address FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoCity, State, Zip FORMTEXT ?????Contact # FORMTEXT ?????Employer FORMTEXT ?????Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Contact # FORMTEXT ?????Legal Father’s Race: FORMDROPDOWN Marital Status of Parents FORMCHECKBOX Married FORMCHECKBOX Separated FORMCHECKBOX Divorced FORMCHECKBOX OtherPutative/Alleged Father’s Name FORMTEXT ?????Email Address FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoSocial Security No. FORMTEXT ?????DOB FORMTEXT ?????Message Contact # FORMTEXT ?????Address FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoCity, State, Zip FORMTEXT ?????Contact # FORMTEXT ?????Employer FORMTEXT ????? FORMTEXT ?????Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Contact # FORMTEXT ?????Putative/Alleged Father’s Race: FORMDROPDOWN Caregiver’s Name (if different from above) FORMTEXT ????? Relationship FORMTEXT ?????Email Address FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoSocial Security No. FORMTEXT ?????DOB FORMTEXT ?????Message Contact # FORMTEXT ?????Address FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoCity, State, Zip FORMTEXT ?????Contact # FORMTEXT ?????Child Name: REF ChildsFullName \h Child DOB: REF ChildsDOB \h Person ID: REF ChildsPersonID \h \* MERGEFORMAT Employer FORMTEXT ????? FORMTEXT ?????Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Contact # FORMTEXT ?????Relative Contact Person For Child/Youth (other than parent) FORMTEXT ?????Contact # FORMTEXT ?????Relationship FORMTEXT ?????Child/Youth Siblings:In CustodyName FORMTEXT ?????SSN FORMTEXT ?????DOB FORMTEXT ?????Sex FORMDROPDOWN Race FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoName FORMTEXT ?????SSN FORMTEXT ?????DOB FORMTEXT ?????Sex FORMDROPDOWN Race FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoName FORMTEXT ?????SSN FORMTEXT ?????DOB FORMTEXT ?????Sex FORMDROPDOWN Race FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoName FORMTEXT ?????SSN FORMTEXT ?????DOB FORMTEXT ?????Sex FORMDROPDOWN Race FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoName FORMTEXT ?????SSN FORMTEXT ?????DOB FORMTEXT ?????Sex FORMDROPDOWN Race FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoName FORMTEXT ?????SSN FORMTEXT ?????DOB FORMTEXT ?????Sex FORMDROPDOWN Race FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoName FORMTEXT ?????SSN FORMTEXT ?????DOB FORMTEXT ?????Sex FORMDROPDOWN Race FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoName FORMTEXT ?????SSN FORMTEXT ?????DOB FORMTEXT ?????Sex FORMDROPDOWN Race FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoName FORMTEXT ?????SSN FORMTEXT ?????DOB FORMTEXT ?????Sex FORMDROPDOWN Race FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoName FORMTEXT ?????SSN FORMTEXT ?????DOB FORMTEXT ?????Sex FORMDROPDOWN Race FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoName FORMTEXT ?????SSN FORMTEXT ?????DOB FORMTEXT ?????Sex FORMDROPDOWN Race FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No ................
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